Ten Years Gone

Remembering March 22, 2006,

The MV ‘Queen of the North’,

her passengers, her crew and the two souls who lost their lives.

Lost Witnesses

April 20, 2006

Good morning passengers and crew, this is the Captain speaking. We are now in Wright Sound. At 25 minutes after midnight, on the early morning of March 22, 2006, the BC Ferry Queen of the North went aground near Juan Point, on Gil Island, situated on our port side, the left hand side of this ship. The Queen of the North started taking on water immediately, and fast. The Captain of the ship made the decision to evacuate the vessel.

At 0140, the Queen of the North sank to the bottom of the sound, where she now lays upright and proud at more than 1400 ft. deep. Though the crew initially believed that they had successfully evacuated all 101 passengers and crew, they eventually had to come to the dark realization that two of the passengers were missing. Mr. Gerald Foisy and Ms. Shirley Rosette went down with the Queen of the North and have not been found. We will now come to a stop and will observe two minutes of silence…

The wreck of the Queen of the North lies directly below us, at more than 1400 ft. of water. All of today’s crew members on the Queen of Prince Rupert have worked on the Queen of the North. The Queen of the North’s crew on the early morning of March 22nd were our shipmates…our heart goes out to them, in support of their professionalism and heroism on that fateful night…

Other heroes are the community of Hartley Bay, the local fishermen, the proud crew of the Canadian Coast Guard ship Sir Wilfred Laurier. Special thanks to the people of Prince Rupert and other communities in the vicinity throughout these trying circumstances.

When sailors first set out to sea, we do it with full admiration of the sea, and with a heart full of ambitions…with no thoughts whatsoever that this beautiful sea could be our worst enemy…the sea took away our flag ship…from her engineers, who have been in every tank, her catering crew who strived to put a smile on our worldwide passengers, to her deckhands who proudly steered her, and her various Captains who had the pleasure and honour of handling her…We will never forget…

The Queen of the North has sailed up and down the Inside Passage for 25 years…and for the years untold, we will sail over her, and we will remember her and the two missing souls, forever.

(This dedication was given Captain Orval Bouchard, Master, Northern Services, onboard the MV ‘Queen of Prince Rupert’ as that vessel sailed to Prince Rupert for the first time following the sinking of the MV ‘Queen of the North’)

VANCOUVER – Jurors deliberating whether a crew member aboard the Queen of the North ferry is responsible for its sinking are combing through complex marine regulations, hundreds of pages of exhibits and the testimony of more than 70 witnesses presented at a trial that lasted nearly four months.

But one thing they don’t have are the results of an investigation by the Transportation Safety Board. (Huffington Post)

The Huffington Post news story goes on to highlight contradictions in the evidence given at trial by certain witnesses and some of the findings in the TSB report. As with all media, story emphasis is often determined by editorial boards and/or the attention span and interests of the audience the article is being directed at. We were pleased to see that at least this news outlet made comment about the lack of evidence given to the jury from a report that took years of dedicated and careful investigation analysis and millions of dollars to complete. Taken as plain evidence, something the jury was not permitted, the TSB report mentions far more than the Huffington Post and other media spoke about. It highlighted organizational failures, poor standards of auditing by Lloyd’s, a lack of attention to the quality of inspections by Transport Canada, substantial safety management system deficiencies and failures at BC Ferries and a lack of regulatory oversight by Transport Canada for the domestic fleet that is echoed in many other Transportation Safety Board Reports and communications. While some of the evidence (3.1 Findings as to Causes and Contributing Factors) examined by the courts regarding events of March 22 is certainly of interest and individual failures have now been addressed through the criminal justice system with a single individual being found guilty of criminal negligence, what of the TSB’s Findings as to Risk (3.2)? And what of the analysis of search and rescue and oil and contaminant clean-up after the incident that was not examined by the TSB. Was it outside their mandate and if so, who was responsible for the lessons learned exercise that should take place after any event of the magnitude of the sinking of a passenger vessel?

While the BCCTS has raised concerns about the standards to which BC Ferries is held and regulated ten years after the sinking of the MV ‘Queen of the North’, we are also sensitive to the voices that weren’t heard during the seven long years up to and including the trial and the evidence that wasn’t presented to the jury that may have been helpful in painting a more complete picture of an organization that has had many incidents over the past five and half decades. Those incidents range from a myriad of near-misses to those resulting in serious injuries to both passengers and crew, potential damage to the environment and loss of life. We are concerned with the silent witness of the TSB report and that of other witnesses who were on scene and unable to speak their stories to the media or the court. We provide some of that witness in the documents links below. Some were the result of Access to Information requests, some are contained in the TSB Accident Investigation Final Report and some are acquired documents and personal letters written to one of our Directors in the aftermath of the incident, silent witnesses now given voice. The Queen of the North and her two lost souls can’t speak for themselves. Now, ten years later we pay our respects to them, to the entire complement of crew and passengers and to their rescuers.

The fourth officer (4/O) did not order the required course change at the Sainty Point waypoint.

Various distractions likely contributed to the 4/O’s failure to order the course change. Furthermore, believing that the course change had been made, the next course change was not expected for approximately 27 minutes.

For the 14 minutes after the missed course change, the 4/O did not adhere to sound watchkeeping practices and failed to detect the vessel’s improper course.

When the 4/O became aware that the vessel was off course, the action taken was too little too late to prevent the vessel from striking Gil Island.

The navigation equipment was not set up to take full advantage of the available safety features and was therefore ineffective in providing a warning of the developing dangerous situation.

The composition of the bridge watch lacked an appropriately certified third person. This reduced the defences and made it more likely that the missed course change would go undetected.

The working environment on the bridge of the Queen of the Northwas less than formal, and the accepted principles of navigation safety were not consistently or rigorously applied. Unsafe navigation practices persisted which, in this occurrence, contributed to the loss of situational awareness by the bridge team.

No accurate head count of passengers and crew was taken before abandoning the vessel, thus precluding a focused search for missing persons at that time.

3.2 Findings as to Risk

In an emergency where abandoning ship is the only recourse, accurate passenger information is vital to both the abandonment and search and rescue (SAR) operations. In the absence of a mandatory requirement for collecting passenger information, the ability for ships’ crews and SAR authorities to verify that all passengers are accounted for is compromised.

As a result of the practice of operating with some watertight doors open, the potential to slow down or stem the progressive flooding was not realized, thereby placing the vessel, its passengers, and crew at undue risk.

The lack of a completed evacuation plan/procedure, in addition to inadequate passenger safety training and drills, left some crew members of the Queen of the North under-prepared to handle the abandonment, thereby placing passengers at risk.

The overall adequacy of passenger vessel evacuation procedures is not fully assessed by Transport Canada, neither at the time of initial certification nor throughout the life of the vessel, increasing the risk to passengers in the event of an emergency.

British Columbia Ferry Services Inc. (BC Ferries) crew members were not fully familiarized with new safety-critical equipment installed during refit, and the company’s training/familiarization program does not take into consideration an individual’s ability to retain skills over a long period of time. As such, BC Ferries does not ensure that all employees are fully competent to perform the duties expected of them, thereby placing the vessel, its passengers, and crew at risk.

In the absence of regulatory or industry-wide standards for ensuring that officers have received up-to-date training appropriate to the equipment they use, some mariners may lack the skills required to operate modern bridge equipment – jeopardizing the safety of the vessel, passengers, or the environment.

Internal and external International Safety Management Code (ISM Code) safety audits have been ineffective in identifying significant safety deficiencies on board BC Ferries vessels. This indicates that measurement of the organization’s safety performance has been inadequate, undermining the objectives of the safety management system.

Canadian regulations regarding the stowage of inflatable liferafts and damage stability of passenger vessels apply lower standards to older vessels even though these are exposed to similar risks. As such, passengers on older vessels are not afforded an equivalent level of safety in the event damage to the hull is sustained below the waterline.

The lack of a requirement for voyage data recorders (VDRs) or simplified VDRs (S-VDRs) on non-Convention vessels deprives the domestic maritime industry of a proven and valuable tool that can improve safety.

Action taken by BC Ferries was not adequate to fully address the risk to safety of the public and the environment posed by crews whose performance had been impaired by the use of alcohol and drugs.

4.1.12 Bridge Watch Composition

On 13 February 2008, the TSB sent MSA 03/08 to TC regarding the interpretation of the Marine Personnel Regulations. In this MSA, the TSB suggested that TC may wish to carry out a review of the existing minimum deck watch requirements with a view to simplifying the language so as to enhance understanding, compliance, and overall safety.

4.3.3 Auditing Voluntary Adopted Safety Management Systems

The objectives of the International Safety Management Code (ISM Code) are to prevent human injury, loss of life, and damage to the environment. Although most vessel operators in Canada are not required to comply, several have done so voluntarily.

The goal of a safety management system (SMS) is to permit participants to detect and prevent unsafe practices and conditions before an accident occurs rather than having others identify safety shortcomings afterward. It is therefore important that, when any non-conformity is reported, appropriate corrective action be taken in a timely manner.

In this occurrence, internal and external audits failed to identify a number of shortcomings. It was also reported that external audits did not always apply the same standards regarding compliance. Major non-conformities, for example, which would have otherwise been cited, may not have been issued because the ISM Code had been adopted voluntarily. Therefore, less emphasis may have been placed on taking corrective action – effectively defeating the objectives of both the ISM Code and an effective SMS.

In Canada, TC has delegated five classification societies108 to perform ISM Code audits on Convention vessels. TC also monitors, via audits, the activities of these classification societies. However, TC’s monitoring, auditing, and overview is for mandatory systems only: TC does not monitor the application of the ISM Code where it has been voluntarily adopted.

The Board is concerned that this lack of consistent application compromises the objectives of the ISM Code. Moreover, the Board believes that, with the large numbers of passengers that may be carried at any one time on a passenger vessel, quality audits are essential in being able to identify deficiencies requiring corrective action. The Board, therefore, will monitor the situation.

BC Coroner’s Investigations:

RCMP Investigation Access for Information Request and Response:

The BCCTS also requested the Coroner’s Inquiry Reports relevant to another incident involving a BC Ferries’ vessel and operations that resulted in loss of life – the MV ‘Queen of New Westminster’/Departure Bay Terminal Early Departure Incident: